AUCTORES
Globalize your Research
Research Article | DOI: https://doi.org/10.31579/2690-1919/130
1 Internal Medicine Service, Department of Medicine, ULS Matosinhos, EPE – Hospital Pedro Hispano, Matosinhos, Portugal.
2 Infectious Diseases Department, Department of Medicine, ULS Matosinhos, EPE – Hospital Pedro Hispano, Matosinhos, Portugal.
*Corresponding Author: R. Correia de Abreu, Local Health Unit of Matosinhos, EPE - Hospital Pedro Hispano, Rua Dr. Eduardo Torres, 4464-513 Senhora da Hora, Matosinhos, Portugal.
Citation: Sara M. Pinto, Batista C., R. C. de Abreu and Neves I., (2020) Characterization of cardiovascular risk factors and Framingham score in an HIV-1 population. J. Clinical Research and Reports. 5(5); DOI:10.31579/2690-1919/130
Copyright: © 2020 R. Correia de Abreu, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 03 November 2020 | Accepted: 16 November 2020 | Published: 19 November 2020
Keywords: cardiovascular risk factors; HIV-1 population; infectious diseases
With the advent of high-potency antiretroviral treatment introduced in 1996, HIV infection ceased to be an acute and deadly disease to become chronic and controllable.However, the early aging of this population, which according to some authors and cohorts, is 10 years less than in the "normal" population, has been studied.Although the realities of these patients comorbidities are well known, the definition of time, when and how or with what to treat still seems to be a matter of debate.The aim of this study is to evaluate the incidence and prevalence according to the state of the art for the non-HIV population of cardiovascular risk factors (hypertension, dyslipidemia, diabetes mellitus) and apply the adjusted Framingham Risk Score by recording analytical and clinical factors in an HIV-1 population with more than 50 years of age, followed in the Infectious Diseases Service for more than 6 months.
The introduction of Antiretroviral Therapy (ART) has led to a change in the paradigm of Human Immunodeficiency Virus (HIV) infection/ Acquired Immunodeficiency Syndrome (AIDS). A condition viewed in the past as rapidly progressive and lethal is now seen as a chronic disease, with the different drugs allowing for an increase in survival rates and improvement in the quality of life. As expected, age related diseases are becoming a more frequent topic in HIV clinics [1].
Although mortality rates in an HIV population are 3 to 15 times superior to the general population, more than half are due to non-infectious complications, such as cardiovascular diseases, essential hypertension, diabetes and chronic kidney disease [1, 2]. These comorbidities are the result of a complex interaction between the virus, the host and ART. The virus is responsible for a state of chronic inflammation with endovascular hypercoagulation [2]. Several studies have showed that uncontrolled viral replication is an independent risk factor for lipid changes such as LDL and triglycerides increase, as well as lowering of HDL [3, 4]. Another mechanism that seems to be present, is the homeostasis of the fat tissue, with HIV promoting a state of lipodystrophy with redistribution of fat, with an increase in visceral deposition. There seems to be also an increase in endothelial inflammation with significant impact in the vulnerable atherosclerotic plaques, related to lymphocytes T CD4+ nadir and the number of HIV copies/ mL in the blood [2, 3, and 5].
The host plays an essential role, not only due to genetic factors that increase the cardiovascular risk per se, but also for other comorbidities and therapeutics. Age, male gender and genetics, are non-modifiable features that influence cardiovascular risk. On the other spectrum, modifiable factors like life style, exercise, smoking, alcohol and other drugs also influence the risk of cardiovascular events and precocious death, with HIV population having a higher prevalence of the last factors mentioned [2, 3].
Last but not least, ART therapy has been associated with lipid changes not fully understood yet. Over the years, there have been several studies with controversial results, with the Swiss HIV Cohort showing a rapid increase in total cholesterol, LDL and HDL after the beginning of ART, contrasting with MACS cohort in which the levels decreased after ART [7, 9, and 10].
All the current guidelines recommend cardiovascular disease prevention, starting with the risk assessment and adjusting treatment to each patients individual profile and risk. Despite the several studies, it is still difficult to define the exact risk score values that should motivate an immediate pharmacological intervention [6, 9, and 12]. Therefore, risk categories were defined to help design an individual approach for each patient according to their specific probability of a cardiovascular event [9]. According to the European Society of Cardiology (ESC) and the American College of Cardiology (ACC), physicians should do a systematic risk evaluation of family history of cardiovascular diseases, smoking, essential hypertension, diabetes and lipid changes. If in healthy individuals this assessment should be made every 5 years after 40 years of age in men and 50 years of age in women, the presence of a condition like HIV should illicit an earlier assessment and intervention if necessary [12].
There are a number of cardiovascular risk scores that assess the probability of an event at 5 years, like the D.A.D. score or a 10year event like Framingham or PROCAM. In the several studies, it seems to be consensual that the D.A.D. score overestimates the 5year risk in HIV patients when compared to Framingham or PROCAM scores. On the opposite side, Framingham underestimates the percentage of low risk HIV patients [6, 9]. Based upon this, Giovanni Guaraldi proposed that Framingham risk score should be adjusted to this specific population, by adding 10 years to the real patient age in order to standardize the results and allow a more rigorous assessment [1, 13]. Patients are considered to be of low risk if they present with an adjusted Framingham score of less than 10%; moderate risk if the percentage stays between 10 and 20 and high risk when above 20%. By defining this, the physician can define an individual strategy towards controlling the risk factors and preventing cardiovascular events.
We conducted a retrospective transversal observational study, by which we characterized a population with HIV-1, with more than 50 years of age in 2019, followed in the Infectious Diseases Service at Hospital Pedro Hispano for more than 6 months. We evaluated their demography, their cardiovascular risk factors, including age and gender, as well as smoking, essential hypertension, diabetes and lipid changes. We also recorded characteristics of their HIV, such as number of years with the disease, treatment, number of lymphocytes T CD4+ and T CD8+ cells and viral load of the virus at each appointment. We later proceeded to analyse their Framingham score and adjusted Framingham score.
The statistical treatment of the data was conducted through Excel and IBM SPSS®, version 20. The study was conducted according to the recommendations of the Declaration of Helsinki of the World Medical Association.
In table 1 we present the sociodemographic characteristics of our 160 appointments, where 75% were man, with a mean age of 60 years old. Patients were infected with HIV between 2 and 31 years, with a mean number of years of infection of 13 and the main form of transmission being sexual in 87.5% of the cases.
Regarding the infection per se, the mean viral load of patients was 97 [0-14366] copies/µL, with most patients having zero copies (89%, n=143). The mean number of TCD4+ cells was 663 [148-1430] and TCD8+ cells was 887 [271-3356]. A total of 47 patients (29%) were defined to have AIDS.
When looking for deeper characterization of HIV infection, we found that most patients – 50.6% (n=81) were in CDCs stage A1 at the time of the appointment, followed by 15.6% in stage A2 or C1 (n=25) and 13.1% (n=21) in stage C2 – see table 2.
A total of 47 patients had an AIDS defining disease through the course of their condition, in which Pneumocistis jirovecii was the most common (n=12), followed by pulmonary tuberculosis (n=10) and non-Hodgkin Lymphoma (n=6). The mean number of years between diagnosis of HIV and opportunistic disease was 10 years.
When looking at the therapy used, the most used drugs belonged to the class of integrase Inhibitors (INIs) used in 97 patients (60.6%) immediately followed by Nucleoside analogue reverse-transcriptase inhibitors (NRTIs) used in 96 patients (60%) – Table 3.
Concerning the cardiovascular risk factors and events, 36% (n=58) of our patients were smokers; 43% (n=69) had essential hypertension; 16% (n=26) had diabetes and the biggest percentage was towards dyslipidaemia, with 86% of patients (n=138) having this disturbance. When looking at the events, 9 patients had myocardial infarctions and there were a total of 4 ischemic strokes (3 in one patient alone).
For further characterization, we found that the mean total cholesterol of our population was 179 [101-287] mg/dL, the mean LDL was 108 [42-195] mg/dL the mean HDL was 49 [24-106] mg/dL and the mean triglycerides was 119 [41-993] mg/dL. Finally, we looked at Framingham risk score and the adjusted score like Guaraldi suggested. We found that most patients, 66% (n=106) had a high risk of 10year mortality and events in the adjusted Framingham risk score compared to 48% (n 77) in the non-adjusted risk score – Table 4. A total of 10 patients switched from low risk to moderate risk and 29 patients switched from moderate risk to high mortality risk, when changing from the general score to the adjusted one
We conducted this analysis in order to characterize a specific HIV population with over 50 years of age that will undoubtedly increase over the next years due to better diagnosis, better care and bigger variety of ART available [14]. Most of our patients were male and contracted the disease through risk sexual contacts, which is in accordance to the Portuguese report regarding HIV/ AIDS infection in 2019 that shows 14.2 male cases per 105 people versus only 5.1 female cases per 105 people and more than 80% being transmission through sexual contact [15].
Another highlight of our cohort, is the fact that most of our patients are probably very well adherent to ART. One can speculate about this fact since mean viral load didn’t reach 100 [0-14366] copies/µL and mean TCD4+ was above 500 [148-1430] cells/µL. Alongside, the fact that most of our patients are in the A1 clinical stage which corresponds to having over 500 T CD4+ cells/µL and no opportunistic infection.
When looking at AIDS defining conditions, of our 47 patients, the most common one was Pneumocistis jirovecii infection, followed by Pulmonary Tuberculosis. According to the 2019 Portuguese report on HIV/ AIDS infection, Pneumocistis jirovecii was still the most common opportunistic condition representing 34.5% of all AIDS defining diseases in Portugal in 2018 [15]. On the other hand, Pulmonary Tuberculosis was less frequent in the report, represented in 11.9% of people with AIDS, coming only after Oesophageal Candidiasis and Cytomegalovirus infection [15].
As expected, the most frequently used class of ART were INIs and NRTIs. These are first-line therapeutics in naïve patients, with Raltegravir being the most frequently used medication [16].
When looking at the cardiovascular risk factors, dyslipidaemia was the most frequent risk factor in agreement several series in the literature. For example, the HOPS study group reports a prevalence of 81% in HIV positive men and 67% among HIV women [17], while ours reports a prevalence of 86% among total population. The second most prevalent risk factor was essential hypertension, present in almost half the patients included. This is also in accordance to several cohorts, with the same HOPS sample mentioning between 54.4 and 57.4% of the HIV population having essential hypertension [17]. Last but not least, diabetes was present in 16% with the MACS cohort mentioning a similar prevalence of 14% (2, 18).
By analysing the Framingham risk score, we realize that most of our patients had a high risk of myocardial infarction or death at 10 years, meaning a risk above 20%. This was the case in both the Framingham and the adjusted Framingham risk score, with the later one including 29 more patients than the first one. As we know, the accuracy of these risk scores for predicting cardiovascular events in HIV-infected patients is not well established [6]. In the Nery et al cohort, only 5.7% of the patients were classified has having high risk, but with a different, younger, population [6]. On the other hand, by applying the adjusted score, the authors also found an increase in the number of patients classified has having intermediate ou high score, as expected [6, 9]. According to Pris et al, Framingham risk score underestimated the cardiovascular event risk in their HIV population, defending that a high proportion of patients classified has having low risk, had already subclinical atherosclerosis [9]. Although a high proportion of our patients had a high risk score, it would be interesting to evaluate if the patients with a low or moderate risk score, already had atherosclerotic changes.
Due to notable extension of life expectancy in HIV-infected patients, cardiovascular complications are becoming more frequent as this population ages. This indicates the necessity of routine screening, appropriate monitoring and management of the broad spectrum of risk factors contributing to cardiovascular complications. Although the several risk scores help stratify the risk of these events, these equations were not developed to assess cardiovascular risk in HIV-infected patients, and their accuracy in this population is still uncertain. A different tool, validated and appropriate for an HIV population is needed, instead of an adjustment of the existing ones.
Conflicts of interest
Sara Moreira Pinto declares no conflicts of interest.
Clara Batista declares no conflicts of interest
R. Correia de Abreu declares to have received honorary fees from Gilead Sciences, Janssen, ViiV / GlaxoSmithKline and Merck Sharp & Dohme and research funding from Merck Sharp & Dohme.
Isabel Neves declares to have received honorary fees from Gilead Sciences, Janssen, ViiV / GlaxoSmithKline e Merck Sharp & Dohme and research funding from Merck Sharp & Dohme.
Sara Moreira Pinto declares no conflicts of interest.
Clara Batista declares no conflicts of interest
R. Correia de Abreu declares to have received honorary fees from Gilead Sciences, Janssen, ViiV / GlaxoSmithKline and Merck Sharp & Dohme and research funding from Merck Sharp & Dohme.
Isabel Neves declares to have received honorary fees from Gilead Sciences, Janssen, ViiV / GlaxoSmithKline e Merck Sharp & Dohme and research funding from Merck Sharp & Dohme.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
